On Ebola we went from global indifference, to global fear, to global response and now to global fatigue. We must finish the job. (Joanne Liu, President, Médicins sans Frontières, July 2015) The international response to the Ebola outbreak in West Africa was slow and inadequate, destroying families, economies and the already fragile health systems of Guinea, Liberia and Sierra Leone. To date, there have been 27 705 documented cases and 11 269 reported deaths. Previous Ebola outbreaks occurred in isolated areas of Central Africa, affected at most a few hundred people, and were rapidly contained. There were more cases and more deaths with this West African outbreak than with all previous outbreaks added together. It is important that lessons are learned so that a humanitarian crisis on this scale never occurs again, whether due to Ebola or another infectious disease.

To the Editor: A recent review article by Dr R Thejpal in CME provided a comprehensive update on the diagnosis, treatment and challenges of early diagnosis of iron deficiency in South African (SA) children. Although several definitive laboratory tests are readily available in SA National Health Laboratory Service (NHLS) laboratories for diagnosing iron deficiency in both children and adults, laboratory testing is expensive and, as noted previously, regions with a high prevalence of anaemia also have a large burden of infectious diseases that invariably become the laboratory priority in resource-constrained settings.

To the Editor : The article by Le Roux et al. raises the question why it is so difficult to re-engineer primary healthcare (PHC) and why the results so far have been disappointing. They highlight the critical role of the district hospital as the hub from which all activities in the rural districts should be co-ordinated. Le Roux et al. write from their own experience at rural hospitals. We agree that there are many examples of well-run public district hospitals with excellent reputations, which have contributed towards improved patient care together with improved health status of the community. Hospitals that have built up reputations as providers of excellent rural healthcare services in the past decades are Elim, Donald Fraser, Gelukspan, Manguzi, Bethesda, Mosveld, Mseleni, Rietvlei, Zithulele, and many more.

To the Editor: Awareness of global health issues is most effectively raised through global campaigns. In 2002 - 2003, the World AIDS Campaign adopted the theme 'Live and Let Live : Stigma and Discrimination' to address various hostile determinants powering HIV/AIDS stigma and discrimination (S&D). Among the effects of HIV/AIDS-related S&D are blame, denial, and difficulties in adhering to treatment. While campaigns raise awareness of global health issues, it was HIV/AIDS that propelled global crusades for advocacy and mobilisation. HIV/AIDS S&D demanded a robust response at all levels of society, as efforts against HIV/AIDS were becoming futile. The various determinants of S&D should be placed in context to address the root causes that are specific to a particular nation or community. Otherwise, campaigns will come and go without a positive impact.

If promulgated as originally proposed, 'shortsighted' changes to the Medical Schemes Act, in particular sections of Regulation 8, will financially hurt both beneficiaries of medical schemes and many private practitioners - via inadequate funder payments for prescribed minimum benefits (PMBs).

Politicians responsible for healthcare delivery, especially those who are medically qualified, should stop 'playing to the crowd' by making irresponsible and premature statements about doctors who sometimes fail to save lives in an under-equipped and dysfunctional public health system.

Recent events in West Africa have highlighted the potential for the viral haemorrhagic fevers (VHFs) to cause considerable mortality and morbidity among heathcare workers. However, this is not a new threat as, although the risk is currently increased, it has always been present. In South Africa (SA) the only endemic haemorrhagic fever is Crimean-Congo haemorrhagic fever, transmitted by the Hyalomma tick,which is ubiquitous in cattle farming areas. Johannesburg, the commercial and transport hub of SA, is unusual in that all cases of VHF seen there are imported, either from rural areas in SA or from countries to the north. Johannesburg functions as the gateway to and from the rest of Africa, and as a destination for more affluent residents of neighbouring countries seeking medical attention. Numerous outbreaks of nosocomial infection have occurred in SA, and these are described in the form of brief case reports.

Between 2009 and 2011, there was an outbreak of measles throughout South Africa (SA). The largest age category infected was children < 5 years of age. In 2014, four patients, with a median age of 4 years and 5 months (range 4 years 3 months - 4.5 years), three males and one female, presented with subacute sclerosing panencephalitis (SSPE). All were infected with measles during the period of the 2009 - 2011outbreak in early infancy, at a time when their immune systems were immature and before they were vaccinated against the measles virus. One patient was immunocompromised, with vertically acquired HIV infection. All the children presented with cognitive and behavioural decline, abnormal movements and medically intractable myoclonic and atonic seizures. Outcome was poor in all and no reversibility was evident with standard therapeutic interventions. Optimal seizure control with carbamazepine is reported in patients with SSPE. Three of our patients who received carbamazepine experienced improved seizure control, but their neuroregression continued. Since submission of this case series, patient 1 (see Table 1) has died, and a further child has presented with the same clinical phenotype as described. On the basis of this clustering of patients in the Western Cape Province, SA, it is important to screen children admitted with acute cognitive decline and intractable seizures for SSPE, especially those who were infants during the measles outbreak.

Using a case study of how a son consented to his mother becoming a body donor, the factors that may have contributed to that decision are outlined. Social and psychological considerations about body donation in general are presented. These are followed by suggestions for organisational improvements for healthcare facilities and medical schools, including ease of access to accurate information for both medical professionals and members of the public. Finally, it is recommended that medical school staff dealing with potential donors and their families should be trained to communicate empathically and with compassion.

Therapeutic options in severe emphysema are limited. Endoscopic lung volume reduction (ELVR) refers to bronchoscopically inducing volume loss to improve pulmonary mechanics and compliance, thereby reducing the work of breathing. Globally, this technique is increasingly used as treatment for advanced emphysema with the aim of obtaining similar functional advantages to surgical lung volume reduction, while reducing risks and costs. There is a growing body of evidence that certain well-defined subgroups of patients with advanced emphysema benefit from ELVR, provided that a systematic approach is followed and selection criteria are met. In addition to endobronchial valves, ELVR using endobronchial coils is now available in South Africa. The high cost of these interventions underscores the need for careful patient selection to best identify those likely to benefit from such procedures.

The legal framework in South Africa (SA) provides for strict requirements regarding prescriptions. However, pharmacists are still confronted daily with illegible handwritten scripts, increasing the risk of medication errors. E-prescribing is being implemented in SA to overcome these disadvantages. The general regulations made in terms of the Medicines and Related Substances Act as well as the Electronic Communications and Transactions Act must be read conjointly for the purposes of understanding the legal framework of electronic prescriptions in SA.

There are approximately 3 million asthma sufferers in South Africa, and the national death rate is ranked as one of the highest in the world. Approximately 5% have severe asthma (uncontrolled despite being adherent on maximal and optimised therapy). Such uncontrolled asthma is associated with high healthcare expenditure and may require treatment with anti-IgE and/or systemic corticosteroids, in addition to inhaler therapy and oral agents. These treatments may be costly, and those such as oral corticosteroids may have potential serious adverse events. There is therefore a need for more effective, affordable and safe therapies for asthma. A new modality of treatment, bronchial thermoplasty (BT), has recently been developed and approved for the treatment of severe asthma. BT involves delivering radio frequency-generated thermal energy to the airways, with the goal of reducing airway-specific smooth-muscle mass. Several clinical studies have confirmed that BT is effective and safe, that it improves control and quality of life in patients whose asthma remains severe despite optimal medical therapy, and that the beneficial effects are sustained for at least 5 years. We provide recommendations for the management of severe asthma, with an emphasis on the role of BT, and endorse the use of BT in patients with severe persistent asthma who remain uncontrolled despite optimal medical therapy as outlined in steps 4 and 5 of the British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN), UK National Institute of Clinical Excellence (NICE) and Global Initiative for Asthma (GINA) guidelines. We outline the context in which BT should be used, how it works, its associated potential adverse events and contraindications, and unanswered questions and controversies.

Background. The management of pregnant patients with mechanical heart valves remains challenging. Both vitamin K antagonists and heparins may be associated with maternal and fetal adverse events.

Method. The Southern African Society of Thrombosis and Haemostasis reviewed available literature and comprehensive evidence-based guidelines for the anticoagulation of pregnant patients with mechanical heart valves. A draft document was produced and revised by consensus agreement. The recommendations were adjudicated by independent international experts to avoid local bias.
Results and conclusion. We present concise, practical guidelines for the clinical management of pregnant patients with mechanical heart valves. Recommendations reflect current best practice, which it is hoped will lead to improved anticoagulation practice in this select group of high-risk patients.

Universal health coverage (UHC) has become a comprehensive global aspiration, and many countries have now committed to processes to deliver it. In pursuit of realising this objective, it will be crucial to find ways to contend with the tensions between supply of and demand for quality services, as well as effective interventions in health systems with finite budgets. In doing so, trade-offs are inevitable and the need to set priorities becomes crucial. The World Health Assembly Resolution (67.23) of 2014, to which South Africa (SA) is a signatory, is entitled 'Health Intervention and Technology Assessment in Support of Universal Health Coverage'. It identifies the 'critical role of independent health intervention and technology assessment' in generating evidence to inform prioritisation, selection, introduction, distribution and management of interventions for health promotion, disease prevention, diagnosis and treatment, rehabilitation and palliation.

Led by the Department of Trade and Industry (DTI), South Africa (SA) is undergoing a process of reviewing and amending national laws governing the protection of intellectual property (IP). This process has the potential to remedy significant shortcomings in the current legislation that allow for the granting of an excessive number of patents, and ever-greening of monopoly periods, at the expense of medicine access. As a member of the World Trade Organization, SA is required to uphold minimum standards of IP protection as defined by the international Agreement on Trade Related Aspects of Intellectual Property Rights (the 'TRIPS' agreement). The TRIPS agreement requires SA to grant 20 years of patent protection on products and processes that meet SA's patentability criteria. These criteria are the standards of novelty, innovativeness and industrial applicability required to receive a patent.

Over the past 15 years, the processes for developing clinical practice guidelines (CPGs) have shifted from their being written by experts (or based on expert opinion) to being largely written by methodologists. CPGs are quality improvement tools, and although they are presented in different ways, their aims are commonly to standardise care, improve its quality and safety, reduce wastage, decrease unnecessary costs, and improve access to care and patient outcomes. With the emergence of international collaborations such as the Guidelines International Network (G-I-N), there have been concerted attempts to standardise CPG writing practices across countries, to increase the credibility of the final products. Without adherence to rigorous guideline development and reporting standards, the considerable time and effort put into developing guidelines may be wasted, as intended users may not have confidence in the recommendations made.

Enshrined in the Bill of Rights of South Africa's Constitution are a number of rights that affirm the democratic values of human dignity, equality and freedom. Section 9(3) states that 'The state may not unfairly discriminate directly or indirectly against anyone on one or more grounds, including race, gender, sex, pregnancy, marital status, ethnic or social origin, colour, sexual orientation, age, disability, religion, conscience, belief, culture, language and birth.' Despite these rights, which are also embodied in policy and law at the highest levels internationally, lesbian, gay, bisexual, trans-gender and intersex (LGBTI) people are subjected to discrimination, abuse, violence and even death because they do not fit into the expectations of what certain sectors of society consider to be the 'norm'.

Viral haemorrhagic fevers (VHFs) include a diverse array of diseases caused by a broad range of viruses transmitted from various animal hosts and originating from almost all the continents in the world. These are potentially fatal and highly transmissible diseases without specific treatments or prophylactic vaccines. As has been demonstrated during the Ebola virus disease outbreak in West Africa, the consequences of VHFs are not limited to specific countries - they may become epidemic, and may have considerable economic impact and disrupt local public health and social service structures. Intensive public health intervention is necessary to contain these diseases. Here we provide a concise overview of the VHFs that are of current public health importance to South Africa.